Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach increasing urinary citrate levels in a patient with recurrent calcium nephrolithiasis who has hypocitraturia, non-acidic urine, and normal serum bicarbonate levels?
For the patient you describe, I would start Moonstone and monitor serum electrolytes and 24 hour supersaturation as I increase the Moonstone dose to optimize treatment. I have no financial interest in this product. Stephen B. Erickson, MD
Do you administer immunosuppression to patients with idiopathic NSIP who have normal lung function and mild to moderate respiratory symptoms?
I think it depends on whether or not it clinically seems that the idiopathic NSIP is driving the mild to moderate respiratory symptoms. If there are no other clear causes of the respiratory symptoms (pulmonary hypertension, cardiovascular disease, airways disease, etc.) and the HRCT imaging findings...
Would you consider using a TNFi in a patient with a family history of demyelinating disease, in the absence of a personal history?
No contraindication based on family history of MS that I am aware of. One could consider MRI head to rule out radiologically isolated syndrome, as a biomarker of risk.
How long do you maintain patients with anti-synthetase syndrome on Rituximab?
This is a challenging question to address, as there are no evidence-based guidelines, and multiple approaches may be attempted. My practice is that once the patient has been stable for at least 6–12 months, and after discussing the risk of flare with them, I attempt to reduce immunosuppression. For ...
Would you escalate treatment for a patient with Crohn disease with changes suggestive of chronic sacroiliitis on MRI but without bone marrow edema or effusion that suggests active inflammation?
I do not quite understand what escalation of treatment you are referring to. However, sacroiliitis needs to be treated depending on the patient's clinical presentation and symptoms. There was a study done with etanercept by Maksymowych et al., PMID 33514428.This study revealed that if erosions are p...
In a patient with anaphylaxis and loss of consciousness from stinging insect, suspected to be yellow jacket, the sIgE was significantly positive to all vespids, but honeybee and paper wasp were only 0.44, would you evaluate further with skin testing to wasp and decide on including wasp in treatment based on skin testing being positive or include it with just the low IgE level?
The wasp IgE may be cross-reactive with YJ, and if the YJ is more than 5 times higher than Polistes IgE then this is almost certainly the case, which would suggest that Polistes VIT is not necessary. However, there is no available test to prove the cross-reactivity, so given the severity of the reac...
How do you manage osteoporosis treatment following parathyroidectomy for primary hyperparathyroidism?
Good question and I usually do this with input from an endocrinologist. I monitor serum and urine calcium and provide supplements and if the bone mass declines, I consult an endocrinologist on the next steps. As a rheumatologist, I am not an expert on this issue.
How should patients time the ingestion of their alendronate and levothyroxine given issues with food/drug interactions?
Since the half-life of levothyroxine is 7-10 days, you can double the dose of Levothyroxine on 1 day and then the next day take only the alendronate. There will not be a significant change in T4 levels.
What prescription or over-the-counter therapies do you recommend for patients with side effects from vismodegib?
For muscle cramps, L-carnitine supplements most definitely, and sometimes a lower dose regimen of a calcium channel blocker like amlodipine if needed. The vismo dosing can be adjusted to allow for breaks as well. For nausea, Zofran can be helpful as well as medical cannabis (which can also help with...
How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?
As with all of medicine this answer depends on the presentation. A thorough review of systems and exam is needed to stratify workup. If we are talking about classic LCV below the knee in an otherwise healthy person, with no other concerning s/sx (as sounds like you are asking), I do generally confir...